Point estimates, sensitivity, specificity, and area under receiver operator characteristic curve for indicators of quality of care from register review and direct observation only compared to direct observation with re-examination.

<p>¹ Direct observation with re-examination.</p><p>² Register review.</p><p>³ Direct observation.</p><p>⁴ Indicators of quality of care from DO+RE were previously published in Miller et al.[<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142010#pone.0142010.ref012" target="_blank">12</a>].</p><p>⁵ Area under receiver operator characteristic curve.</p><p>⁶ Children under 12 months of age.</p><p>Point estimates, sensitivity, specificity, and area under receiver operator characteristic curve for indicators of quality of care from register review and direct observation only compared to direct observation with re-examination.</p

Differences in estimates of indicators of quality of care from register review for children observed by the survey team and children not observed.

<p>¹ Children under 12 months of age.</p><p>Differences in estimates of indicators of quality of care from register review for children observed by the survey team and children not observed.</p

Characteristics of the sample of sick children by recruitment method.

<p>Characteristics of the sample of sick children by recruitment method.</p

Proportion of deceased infants and children who experienced each delay in the “Three Delays-in-Healthcare” model.

Proportion of deceased infants and children who experienced each delay in the “Three Delays-in-Healthcare” model.</p

Proportion of infants and children who experienced each delay in “Three Delays-in-Healthcare” framework by age group, country site, sex, and site of death.

Proportion of infants and children who experienced each delay in “Three Delays-in-Healthcare” framework by age group, country site, sex, and site of death.</p

Venn diagram of each type of delay among deceased infants and children (N = 1,326).

Venn diagram of each type of delay among deceased infants and children (N = 1,326).</p

CHAMPS consortium members.

Delays in illness recognition, healthcare seeking, and in the provision of appropriate clinical care are common in resource-limited settings. Our objective was to determine the frequency of delays in the “Three Delays-in-Healthcare”, and factors associated with delays, among deceased infants and children in seven countries with high childhood mortality. We conducted a retrospective, descriptive study using data from verbal autopsies and medical records for infants and children aged 1–59 months who died between December 2016 and February 2022 in six sites in sub-Saharan Africa and one in South Asia (Bangladesh) and were enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS). Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the receipt of clinical care in healthcare facilities were categorized according to the “Three Delays-in-Healthcare”. Comparisons in factors associated with delays were made using Chi-square testing. Information was available for 1,326 deaths among infants and under 5 children. The majority had at least one identified delay (n = 854, 64%). Waiting >72 hours after illness recognition to seek health care (n = 422, 32%) was the most common delay. Challenges in obtaining transportation occurred infrequently when seeking care (n = 51, 4%). In healthcare facilities, prescribed medications were sometimes unavailable (n = 102, 8%). Deceased children aged 12–59 months experienced more delay than infants aged 1–11 months (68% vs. 61%, P = 0.018). Delays in seeking clinical care were common among deceased infants and children. Additional study to assess the frequency of delays in seeking clinical care and its provision among children who survive is warranted.</div

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Tables A, B and Figs A-D. Table A. Summary of DeCoDed causes of death for infants and children aged 1–59 months who died in the CHAMPS network (N = 1,326). Table B. Proportion of deaths that had experienced each delay in the 3 delays model by site, sex, age group, causes of death, and site of death, N = 1,326. Fig A. Highest level of healthcare facilities in which deceased infants and children received clinical (N = 1,326). Fig B. Venn diagram representing the intersectionality of care for infants and children in the CHAMPS Network between outpatient clinical visits, hospital clinical visits and traditional healing (N = 1,326). Fig C. Proportion of delays in the “Three Delays-in-Healthcare” model among deceased infants and children by country site by age. Fig D. Frequencies of delays in the 3 delays model (A) and frequencies of specific challenges (B) for the top ten DeCoDed causes of death anywhere in the causal chain. (DOCX)</p

STROBE checklist.

Delays in illness recognition, healthcare seeking, and in the provision of appropriate clinical care are common in resource-limited settings. Our objective was to determine the frequency of delays in the “Three Delays-in-Healthcare”, and factors associated with delays, among deceased infants and children in seven countries with high childhood mortality. We conducted a retrospective, descriptive study using data from verbal autopsies and medical records for infants and children aged 1–59 months who died between December 2016 and February 2022 in six sites in sub-Saharan Africa and one in South Asia (Bangladesh) and were enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS). Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the receipt of clinical care in healthcare facilities were categorized according to the “Three Delays-in-Healthcare”. Comparisons in factors associated with delays were made using Chi-square testing. Information was available for 1,326 deaths among infants and under 5 children. The majority had at least one identified delay (n = 854, 64%). Waiting >72 hours after illness recognition to seek health care (n = 422, 32%) was the most common delay. Challenges in obtaining transportation occurred infrequently when seeking care (n = 51, 4%). In healthcare facilities, prescribed medications were sometimes unavailable (n = 102, 8%). Deceased children aged 12–59 months experienced more delay than infants aged 1–11 months (68% vs. 61%, P = 0.018). Delays in seeking clinical care were common among deceased infants and children. Additional study to assess the frequency of delays in seeking clinical care and its provision among children who survive is warranted.</div

PRISMA flow diagram for case selection.

Delays in illness recognition, healthcare seeking, and in the provision of appropriate clinical care are common in resource-limited settings. Our objective was to determine the frequency of delays in the “Three Delays-in-Healthcare”, and factors associated with delays, among deceased infants and children in seven countries with high childhood mortality. We conducted a retrospective, descriptive study using data from verbal autopsies and medical records for infants and children aged 1–59 months who died between December 2016 and February 2022 in six sites in sub-Saharan Africa and one in South Asia (Bangladesh) and were enrolled in Child Health and Mortality Prevention Surveillance (CHAMPS). Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the receipt of clinical care in healthcare facilities were categorized according to the “Three Delays-in-Healthcare”. Comparisons in factors associated with delays were made using Chi-square testing. Information was available for 1,326 deaths among infants and under 5 children. The majority had at least one identified delay (n = 854, 64%). Waiting >72 hours after illness recognition to seek health care (n = 422, 32%) was the most common delay. Challenges in obtaining transportation occurred infrequently when seeking care (n = 51, 4%). In healthcare facilities, prescribed medications were sometimes unavailable (n = 102, 8%). Deceased children aged 12–59 months experienced more delay than infants aged 1–11 months (68% vs. 61%, P = 0.018). Delays in seeking clinical care were common among deceased infants and children. Additional study to assess the frequency of delays in seeking clinical care and its provision among children who survive is warranted.</div